Diabetes Self-Management (DSME) Education

Provider Resource Toolkit

UnitedHealthcare/Medicaid Managed Care Organization Workgroup

December 2015

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Empowering Patients, Improving Outcomes Studies demonstrate that patients who participate in diabetes self-management education (DSME) programs are more likely to

1, 2:

• Use primary care and preventive services; • Be more proactive in their care; • Have delayed onset or escalation of diabetes; • Take medications as prescribed; • Have improved clinical outcomes, such as better control of their HBA1c

levels, blood pressure and LDL cholesterol; and • Have lower health care related costs.

1 American Association of Diabetes Educators. 2015. Why refer for diabetes education? Retrieved March 15, 2015, from American Association of Diabetes Educators: 2 Diabetes Educators: Supporting You, Empowering Your Patients. AADE PowerPoint. 2015.

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Contents

How to Locate a DSME ............................................................................................. 4

AADE Accreditation and ADA Recognition ............................................................. 5

Community-Based Programs ..................................................................................... 6

Joint ADA, AADE and DSME Statement ................................................................. 7

Prevent Diabetes Stat ................................................................................................. 7

Provider Tools – Reference Articles .......................................................................8,9

Referrals and Communication .................................................................................10

Patient Barriers .........................................................................................................10

Closing the Loop on Communication and Following a Patient’s Progress .............10

Doctor/Patient Relationship .....................................................................................11

Motivational Interviewing .......................................................................................11

Additional Resources ...............................................................................................12

Provider Focused Infographic: .............................................................................12

Patient Focused Infographic: ................................................................................12

References ................................................................................................................13

This toolkit was supported by the Pennsylvania Department of Health through the “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health” (DP13-1305) federal grant from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

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How to Locate a DSME

To find a diabetes self-management education (DSME) provider in your area, please go to the Pennsylvania Department of Health Diabetes Webpage at: http://www.doh.pa.gov/diabetesmap

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AADE Accreditation and ADA Recognition There are two organizations that certify diabetes self-management education (DSME) programs as providing evidenced-based education and support services for diabetes management. These certifying organizations are the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA). In order to become certified, a program must meet the 10 National Standards for Diabetes Self-Management Education and Support. The national standards are approved and updated every five years by a task force of experts in diabetes care and management. The task force consists of experts from the areas of public health, underserved populations (including rural primary care and other rural health services), individual practices, large urban specialty practices and urban hospitals. Additional task force members have included individuals with diabetes, diabetes researchers, certified diabetes educators, registered nurses, registered dietitians, physicians, pharmacists and psychologists. Key components of the national standards are to ensure programs have an adequate organizational structure to support the delivery of services and external stakeholder input to ensure program quality and a clear understanding of the target population the program is trying to reach. Specifically, the standards address having the proper staff to deliver the program, curriculum that meets best practices, and individualized care and support plans for each participant. To address lasting care and quality, programs are also responsible for personalized follow-up plans, communicating progress to the referring doctor and engaging in continuous quality improvement to address any service gaps. In depth information on DSME National Standards can be found at: Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., & Youssef, G. (2013). National standards for diabetes self-management education and support. Diabetes care, 36(Supplement 1), S100-S108. http://care.diabetesjournals.org/content/35/11/2393.full A two-page, color PDF document from AADE, “Diabetes Educators: Supporting You, Empowering Your Patients” is available at: https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/ProviderBrochure_Downloadable_Final.pdf

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Community-Based Programs

Community-based lifestyle intervention programs can be an important part of a health care team. Adding individualized and evidence-based programs like diabetes self-management education (DSME) to a patient’s ongoing care plan can be an effective means of both preventing chronic disease complications and increasing patient agency as part of his/her health care team. These community-based programs want to help their communities, but they need referrals from physicians. They have limited resources for promoting their services, and that’s where primary care providers can help. By reaching out and working with these programs, you can not only help your patients but also improve your ability to effectively manage your patients’ chronic diseases. An empowered, educated and supported patient will more efficiently implement your chronic disease treatment care plan.

G e t t o k n o w y o u r C o m m u n i t y - B a s e d R e s o u r c e s

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Joint ADA, AADE and DSME Statement

Diabetes self-management education and support (DSME/S) is a critical component of diabetes care. Referring patients to an appropriate program may not be as straightforward as it seems. In order to streamline that referral process, the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics have released a joint position statement highlighting the importance of DSME/S as part of routine care and providing an algorithm outlining four critical points in time when it is recommended to assess patients’ need for DSME/S referral, which include:

1) At diagnosis,

2) Annually

3) At the development of complicating factors affecting self-management, and

4) At a transition of care. In addition to highlighting these junctures, the statement also outlines the educational focus at each of these junctures.

Press Release http://www.diabetes.org/newsroom/press-releases/2015/joint-statement-outlines-guidance-on-diabetes-self-management-education-support.html? Full Text http://care.diabetesjournals.org/content/38/7/1372.full.pdf+html Prevent Diabetes Stat

A joint initiative between the American Medical Association and The Centers for Disease Control and Prevention, Prevent Diabetes STAT, aims to inform both health care providers and the public about the importance of preventing type 2 diabetes and raise awareness of the evidence-based Diabetes Prevention Program.

To learn more about the initiative and download the toolkit, visit: http://www.ama-assn.org/sub/prevent-diabetes-stat/

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Provider Tools – Reference Articles

• American Association of Diabetes Educators

• American Association of Diabetes Educators. 2015. Why refer for diabetes education? Retrieved March 15, 2015, from American Association of Diabetes Educators: https://www.diabeteseducator.org/practice/provider-resources/why-refer-for-diabetes-education

o This portion of the AADE website provides information on what DSME is as well as provider information regarding referrals, follow-up and DSME benefits. The information is summarized in the handout below:

• “Diabetes Educators: Supporting You, Empowering Your Patients”

https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/ProviderBrochure_Downloadable_Final.pdf

o This is a color, two-page PDF “Diabetes Educators: Supporting You, Empowering Your Patients” produced by AADE that can be printed and distributed to your primary care providers.

o A PowerPoint presentation of the documents is also available here: https://www.diabeteseducator.org/practice/practice-documents/reaching-prescribers.

• Funnell, Martha; Anderson, Robert. Empowerment and Self-Management of

Diabetes. Clinical Diabetes July 2004 vol. 22 no. 3 123-127. o This resource explains the standard of care for diabetes and the

importance and efficacy of empowerment and self-management.

• Joslin Diabetes Center. 2015. Diabetes Education: Why it’s so crucial to care. Retrieved March 13, 2015, from Joslin Diabetes Center: http://www.joslin.org/info/diabetes_education_why_its_so_crucial_to_care.html

o Joslin Diabetes Center is a leader in diabetes education and provides many resources on the importance and effectiveness of DSME.

• Magee et al., M. (2011). Diabetes Self-management Education Program for

African Americans Affects A1C, Lipid-Lowering Agent Prescriptions, and Emergency Department Visits. The Diabetes EDUCATOR , 95 - 103.

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o This research study conducted through a community-based education site (public library) demonstrated a reduction in A1C levels and reduced emergency room visits for uncontrolled diabetes.

• Martin AL. 2013. The future of diabetes education: expanded opportunities

and roles for diabetes educators. The Diabetes Educator. 2013. o This literature review found an increasing need for diabetes educators

and DSME as the population with diabetes continues to rise. Additionally, effective promotion of DSME benefits is needed to ensure utilization of DSME.

• Moran, K., Burson, R., Critchett, J., & Olla, P. (2011). Exploring the cost

and clinical outcomes of integrating the registered nurse–certified diabetes educator into the patient-centered medical home. The Diabetes Educator, 37(6), 780-793.

o This study found significant improvement in A1C, fasting glucose and LDL when a certified diabetes educator (CDE) was used to assist diabetes patients in a patient-centered medical home.

• Siminerio LM, Ruppert K, Emerson S, et al. 2008. Delivering diabetes self-

management education (DSME) in primary care. Dis Manage Health Outcomes. 16(4): 1-6.

o This study looked at the effect point-of-service diabetes education had on patient outcomes. It concluded that DSME delivering at POS provides an effective means of educating patients who do not receive regular DSME services but that more research needs to be done to increase DSME access.

• Stenson et al., B. (2011). Monitoring in Diabetes Self-Management: Issues

and Recommendations for Improvement. POPULATION HEALTH MANAGEMENT, 14 (4), 189-197.

o This collection of thought leader discussions found that self-management and decision making skills are essential in managing diabetes. Decreasing barriers to DSME is critical for people with diabetes in learning these skills.

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Referrals and Communication

Bi-directional communication between PCPs and DSME programs provides holistic care and ensures all members of a patient’s health care team are fully informed. By initiating and maintaining contact for DSME providers, referral to those providers becomes more streamlined, and benefit to the patient increases because of the efficiency of communication.

Patient Barriers

Many patients face barriers attending diabetes self-management education (DSME) including time restrictions, travel considerations, proximity to DSME, financial concerns and patient agency. These barriers are not always apparent, and PCPs can help overcome these barriers by talking through these issues with patients (or assigning to a care team member) to ensure they can attend classes once a referral is made. If a good relationship with DSME programs is made, the discussion of these barriers and help in overcoming them can be done in partnership with those programs.

Closing the Loop on Communication and Following a Patient’s Progress

After establishing a relationship through phone calls, emails or a site visit; clinicians and DSME providers can maintain a more thorough dialogue regarding patient progress and outcomes so each member of the health care team is fully informed.

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Doctor/Patient Relationship

The doctor-patient relationship is important in chronic disease management. Ensuring patients are fully informed on their options regarding their own care, including attending diabetes self-management education (DSME) and other chronic disease self-management education courses, is critical in making them proactive in their health care. In order to overcome patient embarrassment, shyness and discomfort, physicians need to create a safe, welcoming space for patients to express their concerns and thoughts regarding their health. Here are some useful resources that demonstrate the importance of an inclusive doctor-patient relationship and can help create that inclusive environment.

Motivational Interviewing

Motivational interviewing and other communication and empowerment building techniques can help PCPs become more aware of the effect of their interactions on patients and how to motivate patients to become more active in their care, attend DSME and adhere to their overall care plan.

Motivational interviewing is a patient-centered counseling technique meant to engage and facilitate agency in the patient. Some of the fundamental components include asking permission, using change and empowerment talk, asking open-ended questions, and assessing readiness for patient change.

For further information on motivational interviewing, please refer to these resources:

Nelson, Joseph. A Motivational Challenge: Blending Practice with Theory. AADE in Practice. March 2014. http://aip.sagepub.com/content/2/2/42.full.pdf

Motivational Interviewing Strategies and Techniques: Rationales and Examples. Sobell and Sobell, 2008. http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

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Additional Resources

These infographics are intended to increase provider and patient awareness and trust in DSME. They are designed to introduce both populations to DSME and not as comprehensive DSME explanations.

The provider infographic can be distributed as a hard copy flyer, in an email or in another digital format.

• Provider Focused Infographic: https://magic.piktochart.com/output/11506549-dsme-clinician-promotion-official

The patient infographic is intended to be given to providers to post in their offices or otherwise provide to their patient population. It is written at a sixth grade reading level per Health Choices requirements.

• Patient Focused Infographic: https://magic.piktochart.com/output/11528264-dsme-patient-promotion-official

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References

• American Association of Diabetes Educators. 2015. Why refer for diabetes education? Retrieved March 15, 2015, from American Association of Diabetes Educators

• Funnel, Martha M., MS, RN. Helping Patients Take Charge of Their Chronic Illnesses. Family Practice Management. 2000 Mar; 7(3):47-51. http://www.aafp.org/fpm/2000/0300/p47.html

• White, Brandi. Using Flow Sheets to Improve Diabetes Care. Family

Practice Management. 2000 Jun; 7(6):60-62. http://www.aafp.org/fpm/2000/0600/p60.html

• Porterfield D, Hinnant L, Kane H, et al. 2010. Linkages between clinical

practices and community organizations for prevention: final report. Research Triangle Institute. Research Triangle Park, NC. pg. 1-134.

• White, Brandi. Making Diabetes Checkups More Fruitful. Family Practice

Management. 2000 Jun; 7(8):51-52. http://www.aafp.org/fpm/2000/0900/p51.html

• White, Brandi. Improving Chronic Disease Care in the Real World: A Step-

by-Step Approach. Family Practice Management. 2000 Mar; 6(9): 38-43. http://www.aafp.org/fpm/1999/1000/p38.html

• Lowes, Robert. Patient-Centered Care for Better Patient Adherence. Family

Practice Management. March 1998:46–57. http://www.aafp.org/fpm/1998/0300/p46.html